Neonatal Problems – Part 2

Gastroesophageal Reflux and Vomiting 
Regurgitation of small amounts of milk or formula is common in neonates due to reduced lower esophageal sphincter pressure. Parents often confuse regurgitation with vomiting. Adequate weight gain in a baby with GER is reassuring but those who fail to thrive or have respiratory symptoms related to feeding should be investigated for anatomic causes of regurgitation. Reflux can be reduced with  thick feeds and feeding in upright position. Regurgitation with stridor and cough should be evaluated for anatomical defects. Potential causes of vomiting include tracheoesophageal fistula with esophageal atresia, GI obstruction or midgut malrotation, intussusception, necrotising enterocolitis  It may also be a symptom of sepsis, raised ICP, inborn errors of metabolism, incarcerated hernia




Diarrhea and Dehydration 
Neonates are susceptible to dehydration and electrolyte abnormalities associated with severe diarrhoea. Bloody diarrhoea may be a symptom of volvulus, intussusception, or necrotising enterocolitis. Abdominal distention may also occur in association with diarrhoea, bowel obstruction, constipation, necrotizing enterocolitis, or ileus due to sepsis. Obtain serum electrolytes, glucose, stool testing and a urine sample in the setting of fever to evaluate for UTI.

Blood in Diaper 
Potential causes include blood from genital tract in girls, anal fissure, swallowed maternal blood, coagulopathies, necrotizing enterocolitis, allergic or infectious colitis, congenital defects or idiopathic. A newborn with a single event of hematochezia and no concerning findings may be observed as an outpatient. Persistent symptoms or concerning exam findings should be further evaluated. 


Constipation 
Infrequent bowel movements in neonates do not necessarily mean that the infant is constipated. Infants occasionally may go without a bowel movement for 5 to 7 days and then pass a normal stool. However, if the neonate has never passed stools, especially if there has not been a stool in the first 48 hours of life, consider intestinal stenosis, Hirschsprung’s disease, or meconium ileus associated with cystic fibrosis. Neonates with constipation should have a careful evaluation of thyroid function and lumbosacral spine for evidence of occult neural tube defects. The diagnosis of Hirschsprung’s disease is supported by absence of feces on rectal examination, a tonic or tight sphincter tone, and an abrupt change in bowel luminal size on barium enema, and is confirmed by a rectal biopsy demonstrating absence of ganglion cells. 



Neonatal Jaundice
Jaundice signifies hyperbilirubinemia and can represent normal new-born physiology or a pathologic process. 

Physiologic jaundice is characterized by a slow rise in bilirubin (<5 milligrams/dL per 24 hours), with a peak of 5 to 6 milligrams/dL during the second to the fourth days of life and a decrease to <2 milligrams/dL by 5 to 7 days. Decreased neonatal hepatic glucuronyl transferase activity, a shortened life span of neonatal red blood cells and relative polycythemia, and decreased intestinal bacterial colonization all lead to an increase in enterohepatic circulation that produces the normal rise in bilirubin seen in physiologic jaundice. 

Breast milk jaundice occurs be due to the presence of substances that inhibit glucuronyl transferase in the breast milk; it may start as early as the third to fourth day and reaches a peak of 10 to 27 milligrams/dL by the third week of life. Cessation of breastfeeding is not routinely recommended. It is unlikely to cause kernicterus and usually can be treated with phototherapy, when necessary. 


Breast feeding (starvation) jaundice occurs when a newborn is exclusively breastfed and the mother’s milk supply is still inadequate. Poor oral intake leads to reduced bowel movement and less bilirubin excretion through the GI tract. Treatment is optimizing the neonate’s feeding pattern with supplementations or donated breast milk. Severe hyperbilirubinemia may require treatment.

Excessive hyperbilirubinemia can lead to permanent brain injury (kernicterus)



Distinguishing between physiologic and pathologic neonatal jaundice is important, and the timing of the onset of jaundice in the newborn provides useful clues. 

Timing:
<24hrs - Congenital or Acquired  infections, ABO/Rh incompatibility, Hematoma (Cephal/IM)
2-3 days - Physiologic
3-7days - Congenital or Acquired  infections, CN Syndrome, Giblert's Syndrome
>7 days -  Acquired infection, Breast milk jaundice, Congenital or acquired hepatitis, Biliary Atresia, RBS membrane of enzyme defects, Metabolic (galactosemia, fructosemia)


Key questions to evaluate jaundice:
  • Day of onset
  • Blood group and Rh status
  • Maternal infections during pregnancy
  • Maternal blood type and RhoGAM® administration
  • Color of stool 
  • Fever
  • Family history of hemolytic anaemia 
  • Conjugate or Unconjugate Hyperbilirubinemia

Scleral icterus is typically noted with serum bilirubin >5 mg/dL. 

Unconjugated hyperbilirubinemia is much more common, presents earlier in the neonatal period, and is related to the normal or abnormal breakdown of hemoglobin, although inherited enzyme deficiencies or infection may be pathologic causes. Conjugated hyperbilirubinemia results from the inability to excrete bilirubin into the bile and intestines and is usually the result of primary hepatic or biliary disease such as biliary atresia or hepatitis. Conjugated hyperbilirubinemia is always pathologic and often presents later in the neonatal period with jaundice, acholic stools, and dark urine.

The treatment of hyperbilirubinemia depends on the cause, but for most cases of unconjugated hyperbilirubinemia, phototherapy is sufficient. For severe cases, exchange transfusion may be required. 




References;
Tintinalli's Emergency Medicine 8th edition

Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic

  

Neonatal Problems – Part 1

Emergency Department visits in neonates are often due to unclear and nonspecific symptoms. Subtle signs may not point to a specific illness. For instance, Respiratory, Cardiac, Abdominal and Metabolic pathologies can all cause respiratory distress. Many visits just need reassurance and understanding of what constitutes normal for a neonate but the key remains to differentiate benign symptoms from potentially life-threatening underlying disease.




Normal Neonatal Patterns
1. Feeding pattern are quite erratic in the few weeks of life. Breastfed infants take shorter and more frequent feeds (q1-3hrs) as compared to formula fed ones. Adequate Intake is considered if weight gain ranges between 20-30gms/day in the first three months. It is important to remember that neonates loose up to 12% (may be more in exclusively breast fed infants) of their body weight in the first week and are back to their birth weight by 15th day of life. 

2. Just like feeding, bowel movements also varies in number, colour and  consistency. 
Meconium (fist stool) is passed within the first 24 hours after birth. Color changes from black->dark green->yellow seedy by day 4. Failure to pass meconium in the first 48 hours of life may suggest Hirschsprung’s disease or cystic fibrosis.  Breastfed infants may occasionally go 5 to 7 days without a bowel movement. In contrast, overfeeding or use of formula that is too high in sugar content also can produce loose stools.

3. Normal respiratory rate in neonates is 30 to 60 breaths/min. Neonates increase minute ventilation almost entirely through an increase in respiratory rate rather than inspiratory volume. A resting RR >60 breaths/min requires evaluation. Observe respirations to determine if breathing is thoracic or abdominal. Since neonates are obligate nose breathers, even nasal congestion may cause respiratory distress. Periodic breathing (alternating periods of a normal/fast/slow rate with pauses of 3-10 seconds between breaths) is common in pre-term infants. Prolonged Apnea (>20 seconds) or apnea accompanied by bradycardia, cyanosis, or a change in muscle tone is abnormal and requires evaluation. 

4. Infants sleep pattern is fragmented ranging from from 20 minutes to 6 hours cycles spread throughout the day and night. By 6 months, most infants are sleeping through the night. It is important to look for any physical reason of unexplained nighttime cry. Benign causes of cry include Reflux, Wet or Soiled Nappies, Hunger, Too hot or too cold, Teething etc. Carefully look for other pathologies in an episode of acute, inconsolable crying. 


Crying

Inconsolable crying requires a thorough history and head-to-toe examination. Here is a list of illnesses presenting as crying. 

CNS: Intracranial Bleed (NAI, VIt K deficiency), Meningitis and Raised ICP
ENT: Choanal Atresia, Otitis Media, URTI
Eye: Corneal Abrasion, FB eye
CVS: Arrythmias, Heart Failure
RSPneumonia
GI: Oral Thrush, Stomatitis, Volvolus, Intussusception, Hernia, Anal Fissure, reflux, UTI, Diaper Rash, Gastroenetritis
GU: Testicular torsion, hair tourniquet, paraphimosis
MSK: NAI, Hair tourniquet 
Metabolic: Inborn errors, hypoglycaemia, Congenital Adrenal Hyperplasia 

If a careful history and complete physical examination does not reveal any source and the infant remains quiet during the ED observation period, reassure and advise follow up with the general practitioner. 

ColicUnknown pathophysiology. Sudden onset of paroxysmal crying, a flushed face, circumoral pallor, tense abdomen, drawn up legs, cold feet, and clenched fists. Colic is defined as a paroxysm of crying for 3 hours per day for 3 days per week over a 3-week period. It is a diagnosis of exclusion. Rule out other sinister causes of irritability.
There is no specific treatment for colic and casual administration of drugs or sedatives is contraindicated. Colic creates immense stress among caregivers stress. 

Cough/Cold: Cough/Runny nose and Sneezing are usually due to Viral URTI. Neonates with underlying pulmonary or heart disease may develop respiratory failure with even mild URTIs. Check for ill contacts and perinatal infectious risk factors. Respiratory symptoms related with feeding might suggest reflux and aspiration or congenital tracheoesophageal fistula. Respiratory difficulty when quiet and improvement during crying suggest choanal atresia. Treat the underlying condition. Do not give cough suppressants to neonates. Treat nasal congestion with instillation of saline drops and bulb suctioning.

Abnormal Airway SoundsMay be related to benign problems. Distinguish between:
1.Stertor (snoring sound due to soft tissue vibrations in nasopharynx). Stertor can be a symptom of choanal stenosis which can be confirmed by inability to pass a small nasogastric tube through the affected nostril is diagnostic of this condition. 
2. Stridor (sign of upper airway obstruction, can be inspiratory or expiratory) commonly occurs due to laryngomalacia. Stridor may also be a symptom of congenital anomalies causing a fixed obstruction (webs, cysts, atresia, stenosis, clefts, and hemangiomas) anywhere from the nose to the trachea and bronchi. Stridor from fixed lesions is often biphasic. 
  • Stridor worsening with cry: laryngomalacia, tracheomalacia, or subglottic hemangioma 
  • Stridor accompanied by feeding difficulties: vascular ring, laryngeal cleft, or tracheoesophageal fistula. 
  • Stridor with hoarseness or weak cry suggests vocal cord paralysis.
  • Stride post intubation: maybe due to subglottic stenosis 
  • Stride with fever: croup, epiglottitis, and abscess 

When the diagnosis is uncertain, admit for observation and evaluation. 
Periodic Breathing: Periodic breathing must be differentiated from apnea. Apnea is cessation of breathing for 20 seconds, or cessation of breathing for a period <20 seconds accompanied by bradycardia, cyanosis, or a change in muscle tone. It signifies critical illness and warrants investigation and admission for monitoring and therapy. Apnea usually indicates respiratory muscle fatigue and impending respiratory arrest. Provide airway and ventilatory support, and search for the cause. If no obvious cause is found, presume sepsis, obtain cultures, and initi- ate broad-spectrum antibiotics and acyclovir if there is concern for herpes simplex virus. 


Abnormal Movements: 
1. Benign sleep myoclonus: Rhythmic myoclonic jerks observed when the infant is drowsy or in quiet sleep and can be suppressed upon touching and/or waking the infant
2. Startle Reflex: Single myoclonic jerk with extension of the arms and legs triggered by noise or tactile stimulation.
3. Seizures: Present with subtle manifestations, such as eye deviation, tongue thrusting, eyelid fluttering, apnea, pedaling movements, or arching, rather than generalized activity. Neonatal seizures usually indicate a severe underlying structural or metabolic problem and are rarely idiopathic.

Eye Discharge: Clear eye discharge with crusting over the eyelashes without associated conjunctival redness or irritation, is commonly seen in neonates and infants and results from narrow or obstructed nasolacrimal ducts. This condition usually resolves sponta- neously and requires antibiotics only when complicated conjunctivitis or dacryocystitis. Ophthalmologic consultation in needed if problem persists past 12 months of age or  if associated with recurrent infections. Causes of Red Eye include Corneal Abrasion, Acute Glaucoma, Conjunctivitis (Gonococcal, Chlamydial, Herpes Simplex) 

References;
Tintinalli's Emergency Medicine 8th edition

Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic

  



Acute Bronchiolitis

Bronchiolitis is a common LRTI in 2 years age group and it is also one of the the leading cause for hospitalization in infants. The most common bus associated with bronchiolitis is RSV (other possible agents are human metapneumovirus, adenovirus, influenza, rhinovirus, and parainfluenza viruses. Following an episode, cough may persist for up to 3 weeks. 


Pathophysiology
The viral infection in bronchiolitis causes inflammation of the lower respiratory tract leading to edema, necrosis, increased mucus production and bronchospasm eventually causing  air trapping, atelectasis, and hyperinflation of the lower airways and increased work of breathing. 






Symptoms
The peak of symptoms is often between the third and fifth day after onset
  • Coughing. 
  • Rhinorrhea, tachypnea
  • Wheezing and Crackles 
  • Use of accessory muscles and subcostal and intercostal retractions
  • Nasal flaring
  • Low grade fever 
  • Irritability, cyanosis, and poor feeding
  • Apnea in infants
  • Dehydration due to increased insensible losses

Risk Factors for severe disease
  • Chronic Lung Disease
  • Age < 3moths
  • Premature Birth
  • Congenital Heart Disease
  • Immunodeficiency 
  • Neuromuscular Disorders

Diagnosis
  • Bronchiolitis is a clinical diagnosis. 
  • No lab tests are useful 
  • Blood tests and CXR: indicated only if other diagnoses need to be excluded or in cases of severe disease (high O2 requirement)

Differential Diagnosis
  • Asthma
  • Pneumonia
  • Foreign Body
  • Cystic Fibrosis

Treatment 
  • Oxygen Target oxygen saturation of >92%.
  • Instillation of saline into the nares followed by suctioning
  • Frequent and smaller feeds to prevent dehydration
  • Caretakers should use frequent hand washing to minimise spread

Controversial Treatment Options:
  • Bronchodilators do not offer any clear benefits and thus should not be given routinely.
  • Inhaled epinephrine should be considered only in severe disease
  • Steroids do not provide any benefit if used alone. However, current guidelines do advocate consideration for steroid use in combination with epinephrine in the treatment of bronchiolitis.24
  • Nebulized Hypertonic Saline: Mixed evidence and not recommended for routine use. It improve mucociliary clearance by loosening mucous plugs through osmotic draw of fluid from submucosal and adventitial spaces. 
  • Ventilatory Support: Noninvasive ventilation may prevent intubation. 
  • Heliox: Heliox does not affect the rates of intubation or mechanical ventilation or length of intensive care admission


Admit if:
  • Risk Factors for severe disease
  • Premature birth
  • Persistent symptoms despite therapy
  • Dehydration, 
  • Spo<90% on room air)
  • Episodes of apnea 

Take Home: 
  • Bronchiolitis affects <2year age group and RSV is the most common bug.
  • Supportive Care and Hydration is the key
  • Most treatment modalities are controversial and thus are not recommend for routine use. Consider using in rapidly deteriorating

References and Further Reading:
  1. Fernandes R, Bialy L, Vandermeer B, et al: Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev 6: CD004878, 2013. [PMID:23733383]
  2. Ralston SL, Lieberthal AS, Meissner HC, et al: Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics 134: e1474, 2014. [PMID: 25349312]
  3. http://pediatrics.aappublications.org/content/early/2014/10/21/peds.2014-2742
  4. https://www.nice.org.uk/guidance/ng9/chapter/1-Recommendations#management-of-bronchiolitis 
  5. http://pedemmorsels.com/bronchiolitis-seriously-what-should-i-do/

Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic